Bare Life: Seeking Dialysis Care on the Borderlands

"Bare Life"

For those that are undocumented, and therefore deemed underserving of care, treatment for chronic illness is sparse and not guaranteed. when this is coupled with higher rates of nutritional diseases NCD (diabetes, high blood pressure, heart disease, obesity -- due to poor nutrition and a reliance on processed foods and sugar which are cheaper but offer energy for work) --the results are an example of extreme stratification in access to healthcare and poor health outcomes.

• they struggle to navigate the public and private healthcare systems in order to secure life saving treatment.
• lived effect of these exclusions (their experiences) with Dialysis patients
• low income, undocumented and uninsured
• excluded from ACA even though they pay taxes

US-Mexico Borderland South of Texas (Rio Grande Valley)

• highest rates of poverty and undocumented immigrants in the US
• Hidalgo County
• highest rate of poverty in the country
• $14,000 average /year
• poorest access to healthcare in the country -30% foreign (97% Mexican)
• few public health services
• poor access to care
• high environmental health risks
• elevated rates of chronic disease
• highest rate of obesity and diabetes in the country
• highest UNINSURED rate in the country -40%
• kidney disease is the result of these heslth issues with one of the highest rates of dialysis in the country
• isolated and unable to travel for treatment lest they risk being deported

End-Stage Renal Disease and Dialysis

• Complete kidney failure which requires a 4 hour treatment 3 times a week or they will die
• side effects: nausea, vomiting, dizziness, fatigue, cramping, before, during, and after treatment
• food restrictions: little fluids, no potassium or phosphorus rich foods
• work restrictions- travel, availability of treatment, coverage under medicare
• Need surgery to implant a arterial fistula to support the port in dialysis
• ideally, patients have a healthy port access (3 months prior), dialysis three times a week, access to a proper diet and work schedule, health insurance for outpatient care
• EMTALA requires that hospitals that accept medicare offer emergency services to everyone regardless of their insurance of immigration status
• PRWORA- left additional coverage up to the states but TEXAS has none
• IIRIRA (Illegal Immigration Reform and Immigrant Responsibility Act) -need to be documented to get healthcare state assistance- Texas
• requires patients to provide a SS# to receive healthcare
• affords serious barriers to healthcare access for the undocumented workers
• They must have 40 working quarters (10 years) to access any care. 
• although most undocumented workers have paid social security and medicare taxes their whole lives, they have no way of earning the legal quarters to make them deserving of healthcare access
• otherwise they can only access care if they pay the full cost of dialysis
• for the undocumented- irregular treatments in hospital emergency rooms become the most common way to access treatment
• emergency dialysis costs almost 4xs more than emergency room dialysis, but it appears to be more important to symbolically remind the undocumented that they are undeserving and unwelcome
• they can qualify for "emergency medicaid" for intermittent services only when their condition qualifies as a true life or death emergency. So they are always at the risk of dying.
• May wait for days in an emergency room to access care if others are more ill or if the machines are all being used
• most cannot get a fistula ($$$) so receive dialysis through a catheter which risks injury to the veins
• associated with higher rates of infection and death
• life expectancy 4-5 years compared to 35 years for regular dialysis patients

Between the Cracks

• while Carlos was granted residency, unlike us citizen and documented parents who can donate "quarter" to sick children to access care, his US citizen children could not do this in Texas, so even though he was legally in the country he could only access emergency care
• stratification results from the inability to work and limited financial assets
• they do not qualify for care and cannot afford to purchase insurance on the ACA marketplace
• also do not qualify for disability but are too sick to work
• no way forward

"Migrants are desired as laborers but excluded from many public benefits"

Policy Implications

• in states that chose not to expand medicare, they also forgo DSH (Disproportionate Share Hospital Funds) for patients that do not qualify for medicare. If they had the hospitals would have more money coming in to serve these patients
• RGV lacks a hospital so it is espacially critical
• why is healthcare a human right only in Emergency Situations?
• why are undocumented bodies considered human and deserving of healthcare only in the case of emergencies?
• why is preventing an immediate death more desirable than providing long term preventative treatment that can prolong life or prevent death altogether?

Healthcare access is shown to be based upon social evaluations of deservingness, belonging, and human rights